What is Orthopedics?

Orthopedics is the branch of medicine that specializes in diseases and injuries of bones. It is a specialty devoted to the diagnosis, treatment, rehabilitation and prevention of injuries and diseases of your body's musculoskeletal system. This complex system includes your bones, joints, ligaments, tendons, muscles, and nerves. Once devoted to the care of children with spine and limb deformities, orthopedics now cares for patients of all ages, from newborns with clubfeet to young athletes requiring arthroscopic surgery to older people with arthritis and osteoporosis.

Humans have had to contend with broken bones or malformed bones since the beginning. A strong man wielding a club or stone axe, common tools and weapons of the time, could splinter bones or disjoint a shoulder or leg. These injuries were probably frequently lethal, especially if the skin was broken and infection set in. Those that healed may well have left the victim with a deformed arm or joint that was permanently out of alignment.

Eventually, physicians developed ways to treat broken bones as evidenced by ancient Egyptian hieroglyphics depicting injured limbs wrapped and braced to heal normally. As wars were waged on a larger scale and weaponry became more efficient and deadly, fractures and other bone injuries became more prominent.

Physicians developed simple prosthetics to replace limbs that were amputated as the result of a wound. A hand was replaced by a cup that fit over the wrist and had a hook attached.

History

The term orthopedics was coined by a French physician, Nicholas Andre, who published a book in 1741 on the prevention and correction of musculoskeletal deformities in children. He united the Greek term orthos, meaning straight, with paedeia, the rearing of children. The term orthopaedics remained in use, though the specialty has broadened much beyond the care of children. Andre's illustration at the beginning of his book, that of a strong post to which is tied a growing but crooked sapling, remains the symbol of orthopedic societies today.

Early orthopedics concentrated on the correction of such childhood conditions as scoliosis (curved back), paralysis as with poliomyelitis, tuberculosis of the bone, and congenital defects such as clubfoot or deformed hip. Gradually, orthopedists included fractures, dislocations, and trauma to the spine and skeleton within their specialty.

Bone is a living and functioning part of the body. A broken bone will generate new growth to repair the fracture and fill in any areas from which bone is removed. Therefore, a bone that is congenitally deformed (from birth) can be manipulated, cut, braced, or otherwise treated to provide a normal form. A broken bone held in alignment will heal and no physical deformity will result.

For decades orthopedics was a physical specialty. The physician provided therapy to manipulate bones and joints to restore alignment, and then applied casts or braces to maintain the structure until it healed. Fractures of the hip, among other injuries, were considered untreatable and they were ignored. The patient was made as comfortable as possible to allow the fracture to heal and then had to adjust his lifestyle to account for difficulty in walking, inability to bend, or other handicaps remaining from healing of the deformed joint.

In the 1930s a special nail was developed to hold bone fragments together to allow them to heal better. A few years later a metal device was invented to replace the head of a femur (thigh bone), which formed part of the hip joint and often would not heal after being fractured. A total hip joint was later invented and it continues to be revised and improved to allow the patient maximum use and flexibility of the leg.

Currently, the orthopedic specialist continues to apply physical methods to align fractures and restore a disrupted joint. Braces and casts still are used to hold injured bones in place to allow them to heal. Now, however, the physician can take x rays to be certain bones are aligned properly for healing to take place. X rays also can be taken during the healing process to ascertain alignment has not changed and healing is occurring apace.

Orthopedic surgery

Bones that are crushed and have little chance of healing can be helped by transplanting bits of bone from other locations in the body to fill areas from which bone splinters were removed. The operating room in which an orthopedic procedure is to take place resembles a woodworking shop. The physician needs drills, screwdrivers, screws, staples, nails, chisels, and other tools to work the bone and connect pieces with each other.

Deformities of virtually any bone can be corrected. Even facial bones that are malformed can be reshaped or replaced to provide a normal face or to correct defects in the oral cavity. Bone transplants from one individual to another are commonplace. The patient who loses a limb from a disease such as cancer can have a normal-appearing prosthesis fitted and can be taught how to use it and attain a near-normal lifestyle.

The orthopedist is skilled in the following areas:

* Diagnosis of your injury or disorder.

* Treatment with medications, exercise, surgery or other treatment plans.

* Rehabilitation by recommending exercises or physical therapy to restore movement, strength and function.

* Prevention with information and treatment plans to prevent injury or slow the progression of diseases.

The orthopedic surgeon is a medical doctor with extensive training in the proper diagnosis and treatment of injuries and diseases of the musculoskeletal system. The orthopedist has completed up to 14 years of formal education:

* Four years of study in a college or university

* Four years of study in medical school

* Five years of study in orthopedic residency at a major medical center

* One optional year of specialized education.

Orthopedists often specialize in areas such as sports medicine, pediatric deformities, facial surgery, hand surgery, and so forth. Each specialty requires training and education specific for that specialty.

New advances

Orthopedic patients have benefitted from technological advances such as joint replacement and the arthroscope, which allows the orthopedist to look inside a joint. The visit will start with a personal interview and physical examination. This may be followed by diagnostic tests such as blood tests, x rays, or other tests. The treatment may involve medical counseling, medications, casts, splints, and therapies such as exercise, diet changes or surgery. For most orthopedic diseases and injuries there is more than one form of treatment. The orthopedist will discuss the treatment options with the patient and help select the best treatment plan that will enable the patient to live an active and functional life.

Many orthopedic surgical procedures no longer require an open incision to fully expose the joint. Now flexible arthroscopes can be inserted into a joint, such as the knee, and can be manipulated through the joint to locate and identify the nature of the injury. Arthroscopy can be used to look into many joints of the body. In fact orthopedic surgeons often speak of "scoping the joint", meaning looking into the joint. These include knees, shoulders, ankles, wrists, elbows, etc. Surgeons even use arthroscopes to look in and operate on the small joints of your jaw.

In arthroscopic surgery, the surgeon inserts the arthroscope (about the size of a pencil) into the joint through a small cut about 0.25 in (0.64 cm) in length. The arthroscope carries fiber-optic lights, is attached to a video camera, and the image is seen on a TV screen, which the patient can also watch if he or she desires. Through two or three other similar 0.25 in (0.64 cm) incisions the surgeon passes other instruments into the joint with which he will manipulate and repair structures in the joint capable of repair in this fashion. The procedure is usually performed in an operating room to maintain maximum sterility but it is an outpatient procedure, meaning the patient goes home the same day, usually one hour after surgery. Anaesthesia is needed and can be either general anaesthesia, epidural anaesthesia or local anaesthesia. The first two are the preferred methods and with epidural anaesthesia the patient can watch the procedure on the TV screen if desired. Physical therapy often is required after surgery to restore flexibility and strength to the joint and prevent muscle mass loss.

Diseases of the bone

Orthopedists are trained in treating several degenerative diseases such as arthritis, osteoporosis, carpal tunnel syndrome, and so on. The treatment options may vary from making diet changes, medications, steroid injections, and incorporating exercise in the daily routine to surgical procedures and hormone replacement therapy.

Arthritis is the condition where the surface of the joint (cartilage) is damaged or worn out causing a painful bone on bone condition. The most common causes are osteoarthritis and rheumatoid arthritis, but there are many less common conditions. The end result is the same in all of them: damage to the smooth surface of the joint producing rough surfaces that are painful when walked on or rubbed against each other. Joint replacement is probably the greatest advance in the treatment of arthritis in the past 20 years. In the right patient, joint replacement can give a new lease on life to people who would otherwise be crippled or confined to wheelchairs.

Total hip replacement is an operation where the surgeon removes the rough surfaces of bone at the joint and replaces them with new smooth surfaces of the implant used. The modern hip replacement implant is complex and made of several components that the surgeon carefully fits together during surgery. Some of the components are made of metal and others of a special hard medical plastic.

In modern hip replacement there are really two major choices. One choice is cementing the implant to the bone. Old studies have shown that cemented implants usually last on average 10-15 years before they loosen and become painful. Modern "third generation" improved cementing techniques may lengthen this period even more. Another choice is fixing the implant to the bone by making the bone grow into a specially prepared surface of the metal implant, so-called "bone-ingrowth" or "porous coated" implants. Bone ingrowth implants were developed because of the need to have implants last longer for young patients (40-50 years old) who had a long time to use the implants. Early studies were promising, but later studies have shown the newer third generation cementing techniques cause cemented implants to last longer than the bone-ingrowth implants. This is the case for the implants on the femur (thigh) side of the joint. Also, bone-ingrowth implants need time for the bone to grow into the implant and therefore can be somewhat painful for a year or more until that occurs. The cemented implants however, are solid as soon as the operation is completed, and therefore are less painful in the early stages. On the socket side of the hip joint, there does not seem to be an appreciable difference between the two. Most members of the American Academy of Orthopedic Surgeons feel that a "hybrid" hip replacement (cemented femur, bone-ingrowth socket) presents the best option today.

Osteoporosis occurs when bone mass is less than one would expect for the average person of a specific age. Osteoporosis can have many causes. The reduction of the female hormone estrogen after menopause is the most common. Persons who have increased thyroid hormone (hyperthyroid) can become osteoporotic. Patients receiving steroids for long periods of time, either as medication or because of adrenal disease (Cushing's disease) are also at risk.

Since calcium is an essential ingredient of bone, it is necessary to have adequate calcium intake either in the diet or in supplements. Without vitamin D, calcium cannot be taken up into the bone and therefore adequate vitamin D intake is also required.

There are several preventative measures that can be followed to help avoid osteoperosis. One of the simplest recommendations is exercise. Exercise is an important factor in maintaining bone mass, especially after menopause (in women). Ensuring sufficient vitamin D intake with 1,000-1,500 mg of calcium supplements per day is suggested for women five years after menopause. Estrogen-Progestin replacement therapy five years after menopause can reduce the chance of osteoperosis, unless the potential for breast cancer is high. In cases where women cannot take estrogens and have evidence of osteoporosis Fosomax is available. Estrogen replacement (combined with progestin) is FDA approved for and has become the defacto standard of care for both the treatment and prevention of osteoporosis in the postmenopausal woman who does not have a history or risk factors for breast cancer, even though its cardiovascular benefits are the more pressing reason for their use.

Record Number: A30434362

SOURCE:
Gale Encyclopedia of Science.  June 2001 pNA.

Full Text: COPYRIGHT 2001 Gale Group